Meeting Growing Demand for PrEP in San Francisco

In mid-November last year, San Francisco AIDS Foundation opened its pilot-phase HIV pre-exposure prophylaxis (PrEP) program at Magnet, its sexual health clinic. PrEP, with the medication Truvada, was approved by the U.S. Food and Drug Administration three years ago on July 16, 2012 in combination with other safer sex practices for the prevention of HIV. The first 20 spots in the PrEP program—a buffer group created to work the kinks out of the system—filled up immediately.

Magnet staff quickly realized they’d have to ramp up their PrEP provisions in order to keep up with the crushing demand for PrEP they were getting from the community. Now, not yet nine months later, more than 350 people have been screened for PrEP at Magnet. The fledgling program boasts zero new HIV infections and more than 94% reported medication adherence.

“It’s still called a pilot-phase program, but it’s beyond that now. It’s the most poorly kept secret, ever,” says Pierre-Cédric Crouch, PhD, ANP, the director of nursing at Magnet.

The three-room clinic in the heart of the Castro neighborhood maximizes it space by squeezing in nine clients per hour. They’re able to enroll five new PrEP clients per day without disrupting the other HIV and STI testing and treatment services currently offered at Magnet—but they have reached a tipping point.

“The most we can see here without impacting our additional services is about 288 people. And we’ve hit that. So we’re faced with this choice—do we decrease our PrEP enrollments in order to accommodate the follow-ups? Or decrease drop-in STI services? Our STI services are important too—and there’s a huge demand. This morning, there was a line out the door for those services: there’s gonorrhea, chlamydia and syphilis still here too.”

Even with the expanded evening and weekend hours, demand far exceeds supply. With eight new people diagnosed with HIV at Magnet in March, two of whom were in the process of seeking PrEP, Crouch is anxious to expand services to meet demand.

“We do amazing work in our three tiny exam rooms down there but we’re overflowing. We’re on top of each other. The faster we can expand, the bigger impact we’ll make. I’d love it if we could get to the point where someone comes in to test for HIV, and if they ask about and want PrEP, I’m able to put them on it the same day. We make recommendations for PrEP based on risk behaviors, but if someone who seems relatively low-risk comes in asking for PrEP, we support their decision. It’s not unheard of for men to withhold information about their sex lives—even here at Magnet—and our job is to make sure people have all the information they need to make informed choices about what’s right for them. Before PrEP, some clients would never bottom or date an HIV-positive partner. PrEP allows them to have the type of sex, and relationships, they want to have. PrEP allows them to live a life they were holding back.”

Space concerns will be eased by the opening of the new Center for Gay and Bisexual Men’s Health and Wellness where Magnet will relocate this fall and the expansion of the PrEP program to the foundation’s headquarters at 1035 Market Street to serve the SOMA and Tenderloin neighborhoods. With additional exam rooms, staff will be able to offer non-occupational post-exposure prophylaxis (nPEP) on-demand in addition to PrEP services for hundreds—if not thousands—of additional clients.

These stand-out PrEP services and resources bring clients from across the Bay Area—and beyond.

One client makes the trek from a small town about two-and-a-half hours north of San Francisco because he is not able to access PrEP through his primary care provider. “He spent 45 minutes reviewing PrEP information on the CDC website with his provider. Then, his provider said he still wasn’t comfortable prescribing it. So he drives to Magnet every few months,” says Crouch.

Providing efficient testing, screening and benefits navigation that comes with accessing PrEP ultimately is at the heart of what makes this PrEP program successful.

Clients ultimately decide if PrEP is right for them. Once they express interest, it’s possible for clients to be enrolled into the program in one visit. The nurse practitioners perform medical evaluations and counsel clients on the health benefits of adding PrEP as part of sexual health maintenance. To medically clear a client to begin PrEP, they do lab work on the spot using a state-of-the-art chemistry analyzer that can measure kidney and liver function in 12 minutes. They also do HIV testing to ensure that clients who start PrEP are HIV-negative. If there aren’t any medical issues, staff counsel clients on PrEP, medication adherence and stigma.

After a client is medically cleared to take Truvada PrEP, they meet with Jayne Gagliano, the Magnet PrEP benefits manager, who helps clients figure out how they can take advantage of existing insurance benefits, MediCal or copay assistance programs to pay for PrEP. Clinic personnel anticipate and work around insurance roadblocks so that clients do not encounter difficulty filling their prescriptions. Magnet does not dispense medications so clients fill their prescriptions at outside pharmacies.

“Some of our clients have never had to take a medication for a chronic condition before. They don’t know how to order refills. So we make sure to help clients with every step of the process—to make it as easy as possible,” says Crouch.

Clients return for a follow-up visit one month after their enrollment visit. So far, 223 people in the PrEP program have completed their month-1 visit. In addition to lab tests to look for potential medical issues, Magnet staff conduct medication adherence checks and PrEP counseling. Because it’s crucial for the drug to be taken daily in order for it to be effective, clients are asked about how many doses of the drug were taken in the last seven days. “This gives us a good idea of problematic versus non-problematic adherence,” says Crouch. “I can tell you that at month 1, only four people reported missing more than four doses in a week. If a client reports missing a dose, we talk to them about what happened and help them come up with a plan so he knows how to handle a similar situation in the future.”

After clients complete their month-1 visit, they return to the clinic every three months—incorporating PrEP follow-up into a regular HIV and STI testing schedule.

Crouch is inspired by the impact he’s seen PrEP make on some clients lives.

“As part of the ongoing counseling we do, we always ask, ‘What do you want to get out of taking PrEP?’ People want to go on PrEP for all kinds of different reasons. They want the added protection against HIV. But decreasing anxiety around HIV is huge. So many people, before they began PrEP, had a lot of anxiety and fear about HIV, so they dragged their feet when it was time to get tested. I’ve seen PrEP help clients be able to have sex without the fear that they previously had. I’ve also had a couple of clients who had positive partners—who were always secretly afraid of getting infected. And it was impacting their relationships. It was amazing to see them do something to improve their relationships with PrEP.”

We believe that San Francisco can be the first U.S. city to end the HIV epidemic. Every day, we provide free prevention and care services to people in hard-hit neighborhoods—and advocate for them to public officials—because we can envision the day when we beat HIV.

San Francisco AIDS Foundation is a California nonprofit public benefit corporation which has been granted tax exempt status under Internal Revenue Code section 501(c)(3). Our Federal EIN is 94-2927405 and our California corporation number is C1241510.